Mid-term Survival and Costs of Treatment of Patients with Descending Thoracic Aortic Aneurysms; Endovascular vs. Open Repair: a Case-control Study

Comparison of short-and long-term outcomes between endovascular and open repair for descending thoracic aortic aneurysm: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate and compare the efficacy of endovascular versus open repair for the treatment of patients with descending thoracic aortic aneurysm (DTAA).

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases for relevant studies was performed. Outcome data, including postoperative mortality and morbidity, operative details, all-cause survival, freedom from aortic-related survival and freedom from aortic-related re-intervention, were independently extracted by two authors in a standardized way.

RESULTS

Twenty-nine studies comprising 49 972 patients (22 049 endovascular repair; 27 923 open repair) were included. Endovascular repair was associated with a significantly lower postoperative mortality rate [odd ratio (OR): 0.57, 95% confidence interval (CI): 0.45-0.72; I 2  = 72.58%] and morbidity. In terms of long-term survival, endovascular repair yielded better freedom from aortic-related survival [hazard ratio (HR): 0.71, 95% CI: 0.54-0.93, P = 0.012] but inferior freedom from aortic-related reintervention (HR: 2.10, 95% CI: 1.45-3.04, P < 0.001). Landmark analysis revealed that the open repair group experienced better all-cause survival beyond 16 months (HR: 1.64, 95% CI: 1.53-1.75, P < 0.001). In addition, in the subgroup of patients with intact DTAA, those who underwent open repair exhibited a higher rate of postoperative mortality (OR: 0.58, 95% CI: 0.38-0.88; I 2  = 83.34%) but had better all-cause survival beyond 7 months (HR: 1.72, 95% CI: 1.61-1.84, P < 0.001) than those who underwent endovascular repair.

CONCLUSION

Among patients treated for DTAA, endovascular repair was associated with better freedom from aortic-related survival, a lower risk for postoperative mortality and morbidity, and shorter lengths of intervention, intensive care unit stay, and hospital stay than those who underwent open repair. Open repair yielded significantly better long-term all-cause survival and freedom from aortic-related re-intervention than endovascular repair.

Costs of endovascular and open repair of thoracic aortic aneurysms

BACKGROUND

Repair of thoracic aortic aneurysms with either endovascular repair (TEVAR) or open surgical repair (OSR) represents major surgery, is costly and associated with significant complications. The aim of this study was to establish accurate costs of delivering TEVAR and OSR in a cohort of UK NHS patients suitable for open and endovascular treatment for the whole treatment pathway from admission and to discharge and 12-month follow-up.

METHODS

A prospective study of UK NHS patients from 30 NHS vascular/cardiothoracic units in England aged ≥18, with distal arch/descending thoracic aortic aneurysms (CTAA) was undertaken. A multicentre prospective cost analysis of patients (recruited March 2014-July 2018, follow-up until July 2019) undergoing TEVAR or OSR was performed. Patients deemed suitable for open or endovascular repair were included in this study. A micro-costing approach was adopted.

RESULTS

Some 115 patients having undergone TEVAR and 35 patients with OSR were identified. The mean (s.d.) cost of a TEVAR procedure was higher £26 536 (£9877) versus OSR £17 239 (£8043). Postoperative costs until discharge were lower for TEVAR £7484 (£7848) versus OSR £28 636 (£23 083). Therefore, total NHS costs from admission to discharge were lower for TEVAR £34 020 (£14 301), versus OSR £45 875 (£43 023). However, mean NHS costs for 12 months following the procedure were slightly higher for the TEVAR £5206 (£11 585) versus OSR £5039 (£11 994).

CONCLUSIONS

Surgical procedure costs were higher for TEVAR due to device costs. Total in-hospital costs were higher for OSR due to longer hospital and critical care stay. Follow-up costs over 12 months were slightly higher for TEVAR due to hospital readmissions.

Case report: Thoracic endovascular aortic repair using a non-touch exclusion technique with a custom-made device for the treatment of a large patent ductus arteriosus

Patent ductus arteriosus (PDA) is a common congenital heart disease affecting roughly one in every 2,000 term births. Although most of the patients are diagnosed and treated during childhood, few cases may persist into adulthood. We presented a 27-year-old male patient with a 20.2 mm diameter PDA who was referred to our hospital with progressive fatigue and exertional dyspnea. Given the potential complications, usual techniques such as coil occlusion and duct occluders were deemed inappropriate for this patient. Thoracic endovascular aortic repair (TEVAR) using a non-touch exclusion technique was successfully performed for this patient. The patient was discharged with no major post-surgical complications. TEVAR could be a new, safe, and effective alternative treatment to other transcatheter procedures for complicated PDAs in some patients.

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis

INTRODUCTION

Since the approval, the TEVAR is widely used for the repair of thoracic aortic aneurysm. However, the long-term mortality and re-intervention rates compared to OSR are unclear. We aimed to compare the effectiveness of the thoracic endovascular aortic repair (TEVAR) with open surgical repair (OSR) specifically for thoracic aortic aneurysms.

EVIDENCE ACQUISITION

We conducted a comprehensive search in MEDLINE, PubMed, EMBASE, CINAHL, PROSPERO, Centre for Reviews and Dissemination, and the Cochrane Library up to November 2020. The main outcomes were early mortality, mid-to-long-term survival, and re-intervention. The quality of the evidence was assessed using the GRADE methodology. All analyses were performed using RevMan with the random effect model and Comprehensive Meta-Analysis software.

EVIDENCE SYNTHESIS

One systematic review and 15 individual studies were included. Pooled analysis showed that 30-day mortality, stroke, renal failure, and pulmonary complications were significantly lower in TEVAR vs. open surgery. The pooled rate of re-intervention significantly favored the OSR. The long-term survival and mortality favored TEVAR and OSR in one and two studies, respectively, but was non-significant in 7 analyzes.

CONCLUSIONS

Early clinical outcomes including the 30-day mortality, stroke, renal failure, and pulmonary complications significantly favored the TEVAR. However, the mid-to-long-term re-intervention rate favored the OSR and long-term survival was inconsistent among the studies. The quality of evidence was very low. More studies with longer follow-ups are needed. The use of TEVAR should be decided by taking into account other factors including patient characteristics and preferences, cost, and surgeon expertise.

The first commercial use of the Valiant Navion stent graft system for endovascular repair of a descending thoracic aortic aneurysm

Objectives

Thoracic endovascular aortic repair (TEVAR) is the standard of care for descending thoracic aortic aneurysms (DTAA), and newer generation stent grafts have significant design improvements compared to earlier generation devices.

Methods

We report the first commercial use of the Medtronic Valiant Navion stent graft for treatment of an 85-year-old woman with a 5.8 cm DTAA and a highly tortuous thoracic aorta.

Results

A percutaneous TEVAR was performed using a two-piece combination of the Valiant Navion FreeFlo and CoveredSeal stent graft configurations for zones 2–5 coverage. The devices were successfully delievered through highly tortuous anatomy and deployed, excluding the entire length of the aneurysm with precise landing, excellent apposition and no evidence of endoleak. The patient tolerated the procedure well and has had no stent graft-related complications through one-year follow-up.

Conclusions

Design enhancements such as a lower profile delivery system, better conformability, and a shorter tapered tip are some of the improvements to this third-generation TEVAR device. Coupled with the multiple configuration options available, this gives physicians a better tool to treat thoracic aortic pathologies in patients with challenging anatomy. The early results are encouraging, and evaluation of long-term outcomes will continue.

Editor's Choice - Incidence of Stroke Following Thoracic Endovascular Aortic Repair for Descending Aortic Aneurysm: A Systematic Review of the Literature with Meta-analysis

OBJECTIVE

Stroke is an increasingly recognised complication following thoracic endovascular aortic repair (TEVAR). The aim of this study was to systematically synthesise the published data on perioperative stroke incidence during TEVAR for patients with descending thoracic aneurysmal disease and to assess the impact of left subclavian artery (LSA) coverage on stroke incidence.

METHODS

A systematic review of English and German articles on perioperative (in-hospital or 30 day) stroke incidence following TEVAR for descending aortic aneurysm was performed, including studies with ≥50 cases, using MEDLINE and EMBASE (2005-2015). The pooled prevalence of perioperative stroke with 95% CI was estimated using random effect analysis. Heterogeneity was examined using I2 statistic.

RESULTS

Of 215 studies identified, 10 were considered suitable for inclusion. The included studies enrolled a total of 2594 persons (61% male) between 1997 and 2014 with a mean weighted age of 71.8 (95% CI 71.1-73.6) years. The pooled prevalence for stroke was 4.1% (95% CI 2.9-5.5) with moderate heterogeneity between studies (I2 = 49.8%, p = .04). Five studies reported stroke incidences stratified by the management of the LSA, that is uncovered versus covered and revascularised versus covered and not-revascularised. In cases where the LSA remained uncovered, the pooled stroke incidence was 3.2% (95% CI 1.0-6.5). There was, however, an indication that stroke incidence increased following LSA coverage, to 5.3% (95% CI 2.6-8.6) in those with a revascularisation and 8.0% (95% CI 4.1-12.9) in those without revascularisation.

CONCLUSION

Stroke incidence is an important morbidity after TEVAR, and probably increases if the LSA is covered during the procedure, particularly in those without revascularisation.

Thoracic Stent Grafts with a Distal Fenestration for the Celiac Axis

Descending thoracic aneurysms can be treated with a stent graft provided that there is sufficient proximal and distal aortic neck length above the celiac axis. One of the options for the treatment of thoracic aneurysms with a too short distal neck is described in this report. For this purpose, a stent graft was constructed with a scallop for the celiac axis. Three cases are presented, and the technical details are described.

Endovascular Repair of Thoracic Aortic Disease: Overview of Current Devices and Clinical Results

Endovascular repair of thoracic aortic aneurysm has become an important treatment modality in patients who are at increased risk for open surgical repair. Since the US Food and Drug Administration (FDA) approved the clinical application of this technology in the thoracic aorta in 2005, there has been a rapid growth in this treatment modality as numerous endovascular devices have been introduced in the application of thoracic aortic pathology. Although thoracic aortic aneurysm is the only FDA-approved treatment indication for endovascular repair, this technology may lead to a broader clinical applicability in other thoracic pathologies. This article reviews the current endovascular devices designed for the treatment of thoracic aortic pathology. These devices are described, and the current clinical results are discussed.

Endovascular Repair For Thoracic Aortic Disease: Tertiary Single-center Experience In Northwestern Greece

The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece.

Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed.

Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft–related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients.

Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.

Endovascular Treatment of Degenerative Aneurysms Involving Only the Descending Thoracic Aorta

Purpose: To determine the efficacy of thoracic endovascular aortic repair (TEVAR) for degenerative aneurysm involving only the descending thoracic aorta (DTAA). Methods: An English-language literature review was performed through PubMed, Scopus, and Google Scholar to identify any study evaluating the outcomes of TEVAR for DTAA. The main endpoints of this analysis were all-cause 30-day and late postoperative mortality. Secondary outcome measures were procedure success, vascular access complications, paraplegia, stroke, early endoleaks during the index hospitalization, aneurysm-related death, reinterventions, and conversion to open repair. To control for the anticipated heterogeneity among small observational studies, absolute values and means were pooled using random effects models; the results are expressed as pooled proportions, means, or risk ratio (RR) with 95% confidence intervals (CIs). Results: Eleven studies reporting on 673 patients (mean age 72.6 years, mean aneurysm diameter 62.9 cm) with DTAA were selected for the analysis. Technical success was reported in 91.0% of patients, and vascular access complications requiring repair were encountered in 9.7% of cases. Pooled overall 30-day, 1-year, 2-year, and 3-year survival rates were 96.0%, 80.3%, 77.3%, and 74.0%, respectively. Five studies compared the results of TEVAR after elective (n=151) and urgent/emergent procedure (n=77); the latter was a predictor of 30-day mortality (17.1% vs 1.8%, RR 3.83, 95% CI 1.18 to 12.40, p=0.025). Paraplegia occurred in 3.2% of patients and was permanent in 1.4% of patients. The stroke rate was 2.7%. Early type I endoleak was observed in 7.3%, type II endoleak in 2.0%, and type III in 1.2% of patients. The mean follow-up of 9 studies was 22.3 months. At 3 years, freedom from reintervention was 90.3%. Death secondary to aneurysm rupture and/or fistula was reported in 3.2% of patients. Conclusion: Current results indicate that TEVAR for DTAA can be performed with rather high technical success, low postoperative morbidity, and good 3-year survival.

A review of follow-up outcomes after elective endovascular repair of degenerative thoracic aortic aneurysms

Long-term outcomes of elective thoracic endovascular aortic repair (TEVAR) for degenerative thoracic aortic aneurysms (TAA) are not well defined. A review of the literature on the follow-up outcomes of elective TEVAR for degenerative TAA resulted in 22 relevant articles. Two- and five-year freedom from aneurysm-related death varied between 93.0% and 100.0%, and 82.4% to 92.7%, respectively. Two-year and five-year all-cause survival ranged between 68.0% and 97.2% and 47.0% to 78.0%, respectively. Follow-up ranged between 17.3 and 66.0 months. Most common endograft-related complication was endoleak, with reported rate between 1.4% and 14.8% during six months up to five years of follow-up. Endovascular reinterventions were reported in 0.0–32.3%, secondary open surgery was needed in 0.0% to 4.7% during follow-up. Aneurysm-related survival rates after elective TEVAR for degenerative TAA are acceptable. However, reported incidences of endograft-related complications vary considerably in the literature, but the majority can be managed with conservative treatment or additional endovascular procedures.

Cost analysis of endovascular versus open repair in the treatment of thoracic aortic aneurysms

OBJECTIVE

For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs (TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance imaging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair.

METHODS

This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention.

RESULTS

Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years old; P = .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (P = 1.0). There was a trend toward more complications in the TEVAR group, although not statistically significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P = .001). However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group.

CONCLUSIONS

Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demonstrated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our institutional data show that with appropriate selection of patients, open repair can be performed safely with low complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA repair.

Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR

PURPOSE

The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR).

METHODS

Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25%), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ).

RESULTS

Primary type Ia endoleak rate was 12% (7/57) and subsequent re-intervention rate was 86% (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28%) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7% (4/57) and subsequent re-intervention rate was 100%. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038).

CONCLUSIONS

CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.

Gore TAG®Thoracic Endoprosthesis: the first US FDA-approved thoracic endograft

Open surgical repair of thoracic aortic lesions carries a significant risk of complications, including death. Minimally invasive approaches, however, may improve outcomes. Clinical trials of the Gore TAG Thoracic Endoprosthesis device indicate that subjects receiving the graft are less likely to experience major adverse events, less intraprocedural blood loss, shorter intensive care unit and hospital stays, and reduced recovery times than surgical patients. The US FDA approved the device in March 2005. Since then, the device has been used widely, although a 0.30% rate of complications related to infolding or partial compression of the device prompted a 'Dear Doctor' letter in January 2006. This article profiles the TAG device and evaluates endografting technology in general.

Thoracic Endovascular Aortic Repair: A Local Single Institution Experience

Introduction: The purpose of this retrospective study was to evaluate the short- to mid-term results of the endovascular repair of thoracic aortic disease and to present an overview of our experience with thoracic endovascular aortic repair (TEVAR) in our institution. Materials and Methods: A retrospective review of all patients who were treated and underwent TEVAR in our institution between August 2004 and November 2009 was conducted. Results: Technical success was achieved in 100% of the patients and the 30-day mortality rate was 0%. Perioperative endoleak was visualised at the end of the procedure in 4 patients. Secondary endoleak was observed in 2 patients. Mean hospital length of stay post-TEVAR was 15.4 days. Postoperative major complications were observed in 4 patients. The 30-day mortality rate was 0%, with 2 mortalities (11.1%) during the follow-up period. Conclusion: This study adds to the growing body of literature that support TEVAR as an effective procedure in the management of thoracic aortic diseases and reflects its feasibility in our population. Further technical advancement in stent grafts, careful selection of patients and standardised peri-procedural care would contribute to further improvements in clinical outcomes. Key words: Endovascular, Stent graft, TEVAR, Thoracic aneurysm, Thoracic dissection

[Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

Volume-outcome relationships in vascular surgery: the current status

Vascular surgery has been widely practiced in hospitals within a general surgical service, although the consequent workload of individual vascular units has been small. There is an increasing body of evidence in favor of a positive relationship between hospital and surgeon volumes and the outcome of arterial surgery. These relationships suggest that vascular surgical procedures might be best placed within a centralized model of care to increase volume and thereby attain best outcomes. This systematic review appraises the current evidence for volume-outcome relationships in vascular surgery from a number of healthcare systems to examine the basis for centralization of vascular surgical services. The index procedures addressed in this review are open or endovascular repair of abdominal aortic aneurysm (AAA), ruptured AAA, descending thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm, along with carotid endarterectomy and lower extremity arterial bypass.

Endovascular repair of thoracic aortic aneurysm

A thoracic aortic aneurysm (TAA) is a potentially life-threatening condition with structural weakness of the aortic wall, which can progress to arterial dilatation and rupture. Today, both an increasing awareness of vascular disease and the access to tomographic imaging facilitate the diagnosis of TAA even in an asymptomatic stage. The risk of rupture for untreated aneurysms beyond a diameter of 5.6 cm ranges from 46% to 74% and the two-year mortality rate is greater than 70%, with most deaths resulting from rupture. Treatment options include surgical and non-surgical repair to prevent aneurysm enlargement and rupture. While most cases of ascending aortic involvement are subject to surgical repair (partially with valve-preserving techniques), aneurysm of the distal arch and descending thoracic aorta are amenable to emerging endovascular techniques as an alternative to classic open repair or to a hybrid approach (combining debranching surgery with stent grafting) in an attempt to improve outcomes.

Comparative analysis of hospital costs of open and endovascular thoracic aortic repair

BACKGROUND

Endovascular technologies represent major advancements in treating descending thoracic aortic aneurysms (DTAA). We compared hospital charges of open thoracic aortic replacement (OTAR) with endovascular repair of thoracic aortic aneurysms (TEVAR).

METHODS

Retrospective analysis of hospital charges related to repair of DTAA (2000-2009). Charges were inflation adjusted for dollars in 2009.

RESULTS

There were 50 OTAR and 50 TEVAR patients. Open thoracic aortic replacement charges were $64 531 (interquartile range [IQR]: 49 000-108 515) versus $61 909 (IQR: 41 307-92 109) for TEVAR(P = .4). A total of 10 patients (10%) died before discharge, with 0 TEVAR deaths (P < .05). For OTAR, supply charges ($9167) accounted for 13% of total charges versus 56% for TEVAR ($40 468), P < .01. Open thoracic aortic replacement length of stay (LOS) was 12 days (6 days intensive care unit [ICU] stay); bed charges comprised 40% of the total charges. Thoracic endovascular aneurysm repair had lower LOS (5days with 2 days ICU stay, P < .001).

CONCLUSIONS

Descending thoracic aortic aneurysm repair remains a formidable operation with significant resource utilization. Thoracic endovascular aneurysm repair does not significantly reduce overall hospital charges due to device costs but demonstrates improved mortality, ICU, and total LOS.

Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies

OBJECTIVES

The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease.

BACKGROUND

The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials.

METHODS

Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies.

RESULTS

Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results.

CONCLUSIONS

Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Endovascular management of thoracic aortic pathology

BACKGROUND

Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date.

METHODS

A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted.

FINDINGS AND CONCLUSIONS

The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.

Experience with Medicare's new technology add-on payment program

We describe the new technology add-on payment (NTAP) program used by the Centers for Medicare and Medicaid Services (CMS) to provide additional payment for breakthrough technologies in the Medicare hospital inpatient prospective payment system (IPPS). We also evaluate spending under the program. Our findings suggest that the criteria established by the CMS to limit qualifying technologies, combined with an improvement in overall payment adequacy for the new technologies that qualify for NTAPs, may represent important steps toward improving value in Medicare.

Thoracic endograft positioning and carotid-subclavian bypass grafting in a patient with a saccular aneurysm at the aortic arch

A 75-year-old man was referred to our hospital because of sudden thoracic pain. A saccular aneurysm of the aortic arch extending on the anterior surface of the aortic arch was found on computed tomographic arteriography. The patient was hemodynamically stable and he was programmed for a staged surgical and endovascular approach (hybrid approach). As a first stage and in order to prevent major cardiac complications due to the overstenting of the left subclavian artery (LSA) with the occlusion of the aortocoronary bypass, the patient underwent a polytetrafluoroethylene bypass graft (GORE-TEX, W.L. Gore & Associates, Flagstaff, AZ) between the LSA and the left carotid artery. Intraoperative arteriography revealed a good patency of the left carotid-subclavian bypass and of the left internal mammary bypass on the left anterior descending artery. As a second stage the endovascular procedure was accomplished 5 days later in the operating room. A Gore TAG stent graft (W.L. Gore & Associates) was deployed in the aortic arch 20 mm proximally to the aneurysmatic segment covering the ostium of the LSA. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day in good general conditions. Hybrid procedures for treatment of aneurysms of the aortic arch or of the descending thoracic aorta are a promising alternative to open surgery especially in high-risk patients, with lower early morbidity and mortality rates. Long-term effectiveness remains to be fully elucidated.

Endovascular Repair of Localized Pathological Lesions of the Descending Thoracic Aorta: Midterm Results

The endoluminal stent-graft represents an attractive and a less invasive technique for treatment of various diseases of the descending thoracic aorta. The purpose of this study was to evaluate the Talent endovascular stent-graft for the treatment of various localized diseases of the descending thoracic aorta. Over a 3-year period, Talent thoracic endografts were placed in 40 patients with a high surgical risk, presenting a localized lesion of the descending thoracic aorta: degenerative aneurysm (n = 13), acute traumatic rupture (n = 11), acute Stanford type B aortic dissection (n = 6), false aneurysm (n = 7), and penetrating atherosclerotic ulcer (n = 3). Fifteen patients (37.5%) were treated as emergencies. The feasibility of endovascular treatment and sizing of the aorta and stent-grafts were determined preoperatively by magnetic resonance angiography (MRA) and intraoperative angiography. Immediate and mid-term technical and clinical success was assessed by clinical and MRA follow-up. Endovascular treatment was completed successfully in all 40 patients, with no conversion to open repair or intraoperative mortality. The mean operative time was 37.5 +/- 7 min. The overall 30-day mortality rate was 10% (n = 4), all in emergency cases, for causes not related to the endograft. The primary technical success was 92.5%. The mean follow-up period was 15 +/- 5 months. The survival rate was 95% (n = 35). Diminution of the aneurismal size was observed in 47.5% (n = 19). We conclude that endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well-selected patients.

Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Thoracic aortic endografting is the treatment of choice for elderly patients with thoracic aortic disease

OBJECTIVE

To assess the effect of age on outcomes following thoracic aortic endografting.

SUMMARY BACKGROUND DATA

Endograft therapy for thoracic aortic disease is rapidly evolving. This therapy is less invasive, and elderly patients with significant medical comorbidities are more frequently referred for endografting. We hypothesized that elderly patients over the age of 75 have worse outcomes after thoracic endografting than patients under the age of 75.

METHODS

We retrospectively reviewed the charts of the first 42 patients who underwent endografting for thoracic aortic pathology. Charts were reviewed for demographics, comorbid conditions, perioperative complications and death, endoleaks, and results at 3, 6, and 12 months. Preexisting medical conditions were also evaluated to determine if any patient characteristics were associated with adverse outcomes. Perioperative morbidity included cardiac, pulmonary, renal, hemorrhagic, and neurologic (stroke and spinal cord injury) complications.

RESULTS

Twenty-four patients were under the age of 75, and 18 patients were 75 or older. Baseline demographics and comorbidities were similar between the 2 groups. There were no differences in operative time, length of stay, perioperative mortality, or the incidence of significant complications between the 2 age groups. Gender, however, was associated with a statistically significant difference between the occurrence of complications, with more women experiencing complications than men (P = 0.026, relative risk = 2.36). One patient (age >75 years) in the entire cohort of 42 (2.4%) suffered a spinal cord injury. At 3 months, endoleaks were more common in the older age group (P = 0.059).

CONCLUSION

Endograft therapy for thoracic aortic disease can be performed safely in elderly patients with no significant increase in perioperative morbidity or mortality compared with younger patients. Female gender is associated with a higher likelihood of perioperative complications, regardless of age. The overall incidence of spinal cord injury is very low. Endograft therapy, when anatomically possible, is the treatment of choice for thoracic aortic disease in elderly patients.

Dislocation of a Stent-Graft Into the Aortic Arch During Endovascular Repair of a Descending Thoracic Aortic Aneurysm

A 59-year-old man showed a saccular aneurysm due to a penetrating atherosclerotic ulcer, as well as a small type B aortic dissection located in the proximal descending aorta. The lesion was treated by the implantation of a stent-graft. On release, the stent-graft dislocated into the aortic arch. Intraoperative angiogram showed free perfusion of the brachiocephalic trunk and left common carotid artery; however, an overstenting of the carotid artery was apparent. Computed tomographic scan exhibited a complete covering of the supra-aortic vessels, and conventional, open aortic arch surgery was inevitable. A partial resection of the proximal part of the stent-graft was performed.